Improvements in communication between police and paramedics implemented after failures at the Bondi Junction mass stabbing might have saved lives in the Bondi Beach terror attack.
The findings from the coronial inquest into the stabbing were handed down on Thursday after being delayed out of respect for the victims of the massacre on December 14.
The 837-page report dedicates many of its recommendations to the shortcomings in co-operation between emergency services responding to the attack on April 13, 2024.
When Joel Cauchi stabbed 16 people at Westfield Bondi Junction in Sydney's eastern suburbs, he revealed there was no clarity about how police and ambulance officers should work together.
"The incident at Bondi Junction made clear that there is an absence of coherent underlying doctrine and a clear framework for interoperability," State Coroner Teresa O'Sullivan said.
The police declaration of a "hot zone" - which means there could be more than one attacker - that prevented paramedics from entering the shopping centre was a "near miss", she found.
"The declaration of a 'hot zone' did not result in extra loss of life ... but it could have," Ms O'Sullivan said.
A lack of radio communication between police and ambulance control rooms and delays in triaging injured patients were also criticised.
But the coroner heaped praise on the subsequent actions of both agencies, which reformed their processes before the formal recommendations were released.
Lessons from the Westfield attack were implemented "seamlessly" in the response to the Bondi Beach shooting, she said.
"I had hoped our community would not need to grapple again so soon with ... another tragic, violent event," Ms O'Sullivan said.
"The ability of paramedics and police working together at Bondi Beach is said to have contributed to the saving of lives."
While the systems of emergency agencies responding to the Bondi Junction stabbing were heavily criticised, the individuals who responded to the stabbing were largely lauded.
Hero cop Amy Scott, who shot Cauchi dead and ended the attack, was "entirely justified and appropriate" in her use of force, the coroner said.
Det Insp Scott - who revealed in January she was undergoing cancer treatment - was commended by the coroner for her ongoing actions in support of those traumatised by the incident.
"She attended court throughout the inquest to provide comfort to others, (she) combined skill and compassion with great humility," Ms O'Sullivan said.
The NSW government says it is considering all 23 recommendations made by the coroner, including the roll-out of "appropriate co-responder models".
"We owe all (first responders) a huge debt of gratitude, and we're very thankful for their service to this state," Premier Chris Minns said in question time on Thursday.
The coroner also recommended the government promote the "Escape, Hide, Tell" slogan to encourage civilians to remain safe when an armed offender was in the loose.
